For more on the debate on Depo-provera, check out:
World Population Day, Womens' Bodies and My Friend Sangini
July 12, 1998, Kathmandu Post
A man is holding a large needle and seems to be stabbing it into the figure of a woman. Below, there is a larger depiction of a hypodermic syringe. The large red letters say simply: The three month needle.
There is no other information on these large advertisements that have started appearing in strategic places around Kathmandu, like bus-stops and pharmaceutical shops. The billboards are advertisements for a synthetic hormonal contraceptive to control fertility - female fertility. No alternatives to Depo-provera (we assume that this is what the advertisements are referring to) are given. Side-effects, of which there could be many, are not mentioned. No information is given about conditions like diabetics and previous jaundice cases that could make it unsafe for a woman to receive the injection. Finally, these advertisements fail to tell you that a woman cannot stop using the injection if she starts suffering from bad side-effects.
But perhaps this sign is not meant to be read by women at all - especially not the women who are going to be injected with the needle. Unlike the advertisements for oral contraceptives like Nilokan, these signs display images not designed to appeal to an urban elite. So who is the projected audience for this sign? The diagrams depict a bikase "villager" with his dhaka topi bending down towards a woman in her choli and patuka. The signs point to a target audience schooled in understanding a bikase diagram with reading skills to understand a simple phrase. Perhaps the targeted audience is the "rural mass" of Nepal? Or more specifically, perhaps the men from rural areas who come down to the Valley for seasonal work who then can act as cultural transmitters of the cosmopolitan developed values of the city when they return home to the villages? Or even more disturbing, perhaps the advertisements do not speak at all to a lay audience, but are targeted directly to such professionals as traditional birth attendants and health post workers working in and out of the Valley?
The positioning of the sign and its site forces us to reevaluate concepts of "reproductive health" that has become prevalent in the Nepali government's national development strategy. Although Safe Motherhood and traditional birth attendant projects were tacked on after the Cairo Conference on Population and Development, it is disturbing to see how much of Nepal's strategies of "reproductive health" are still very much tied to strong notions of population control. Women, within these models, are still very much target groups to be worked upon: not human beings with agency who can understand their own bodies and need information about what is being done to them.
As Population Day is celebrated in Nepal with a host of programs sponsored by the population control lobby, the Malthusian assumptions that have lost validity or are being contested in most other parts of the world still seemed to be depressingly in vogue in ours. The time has come to ask those questions that have become common currency in the rest of the world but seems to have eluded the public dialogue in Nepal: why is rising population considered such a big problem? And is the control of women's fertility the only way to think about it? As the "solution" to everything from poverty to environmental degradation, population control has managed to corner a large slice of the development pie. Among other strategies, contraceptives like Depo provera and Norplant, in spite of the controversies they have raised in other parts of the world (Depo provera and Norplant were banned in the US and India until a few years ago, and were highly criticized by the activist movement in Bangladesh), are still accepted by the Nepali government as valid strategies to pursue in its quest for development. Synthetic hormonal injections by their nature tend to locate the control of fertility in the hands of health bureaucrats and medical institutions.
In the context of Nepal, where women are imbedded in larger social systems and are only marginally involved in the decisions that control their fertility, promoting injections means that the body of the woman is doubly acted upon: once by the family and other social institutions, and the second by the medical apparatus of the state.
The health care system of Nepal, patched together with few resources and even fewer trained personnel, is a dubious system to carry out this mission of "choice" advocated by international donors who see contraceptives as a way to empower women and free them from their life-threatening task of childbearing. Many women who are injected with a implant like Norplant are not able to voice their side effects as anything other than "women's illnesses" for which there is no conceivable cure. Medical personnel, used to treating women's perceptions of their own health from the lenses of their medical authority, are hard pressed to take any complaints seriously. Tied to this is the notion that all injections are "good medicine", and you have the perfect conditions of Third World female bodies being the physical testing ground for the ideologies of an unholy trinity: transnational pharmaceutical companies, Malthusian international aid, and national development.
The idea of "choice", popular among international donors, becomes a mockery in these circumstances. As the advertisements point all too clearly, the (female) targets of population control are not even afforded the choice of a nice array of hormonal injectibles, far less anything more easily controlled and less invasive like female condoms or diaphragms. Their rights to information to what is being done to their bodies and their rights to safer methods of fertility control are overridden to the larger imperatives of a nation-state and international aid regime frenetically obsessed with "development".
One of the advertisements for the three month needle has a nice addition - a cursive hand flows airily across the white board and informs me: Sangini is your friend. I assume that Sangini (friend) is the name of the brand of Depo provera and therefore it points to some sort of confidential, trusting relationship that I should attribute to the injection due to its name. As a not-so-trusting Third World female subject, I am not sure what this newfound "friend" can do to my body and to those of my friends. And I would feel better if I knew of the choices not listed in the board - of other ways to approach the question of fertility; of men's bodies as a site for fertility control and of less invasive technologies of contraception. It is way beyond time in Nepal to view women as knowing, thinking subjects actively involved in their own health and fertility.
(Sushma Joshi is editor of the BOL! E-mail network and co-ordinator of the Global Reproductive Health Forum in South Asia, Harvard University)